Request for Remittance through NEFT / RTGS

Branch:
(To be filled in by the applicant in BLOCK LETTERS)

Request: NEFT RTGS Cheque is mandatory, if request not provided by customer directly.

DETAILS of the APPLICANT (Remitter)

Title of Account: Account No.:
Branch where account is maintained: Type of Account: Savings Current Cash Credit
Mobile Number: Overdraft NRE NRO
Status: Resident Non-Resident Email Id:

DETAILS of BENEFICIARY BANK

Bank Name: Branch:

City: IFSC Code:

DETAILS of BENEFICIARY
Beneficiary Bank Account Name (As per Beneficiary’s Bank record):

Beneficiary Address:
Beneficiary Bank Account Number: Beneficiary Bank Account Number Re-confirmed:

Type of Account: Savings Current Cash Credit Overdraft NRE NRO

Amount to b e remitted: ` (in figures) (Rupees in words)

Bank Charges: `

Remark for Remittance: (to be captured)

Remit the amount as per above mentioned details, by debiting my / our account or I/we herewith tender cheque no. dated

for ` /- drawn on our account for the amount of remittance plus your charges.

Rupees in words :

TERMS AND CONDITIONS

I/We abide by the following terms and conditions:
1. It is being understood that the remittance is to be sent at my/our own risk and responsibility and on the distinct understanding that no liability whatsoever is
to be attached to the Bank for any loss or damages arising or resulting from delay in transmission, delivery or non-delivery of the message or for any mistake,
exchange or error in transmission or delivery thereof or in deciphering the message for whatsoever cause or from its misinterpretation when received or the
action of the destination Bank or due to RBI (Reserve Bank of India) RTGS / NEFT system not being available or failure of internal communication system at
the recipient bank/branch or incorrect information provided by me/us or any incorrect credit accorded by the recipient bank/branch due to information
provided by me/us or any act or event beyond control or from failure to properly identity the person’s name.
2. I/We understand that the process of RTGS / NEFT request is subject to availability of clear funds in my/our account at the time of processing the request.
3. I/We understand that RTGS / NEFT request submitted after the cut off time will be processed/sent on the next working day.
4. I/We understand that the RTGS / NEFT request is subject to the RBI regulations and guidelines governing the same.
5. I / We agree that the credit will be effected solely on the beneficiary account number information and beneficiary name particulars will not be used for the
same.

Date ________________________________ Signature of account holder/s ______________________________________

FOR BANK USE
435-Ver 1.1-Jan 2014 / M024 / Jan 18 / 2.4

Debited Applicant's A/c. Cheque No. & Date

Request Received Date & Time Cheque Amount

Verified cheque details and Signature Request Processed Date & Time

Signature verified by BOM / BH Cheque verified for stop payment (for NEFT)

RTGS – UTR No. SDC / Transaction No.

NEFT Ref No.

DCB Bank Limited Authorised Signatory (Maker) Authorised Signatory (Checker)